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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. Mental Health in Native Communities: Concepts and Care Johns Hopkins University - Bloomberg School of Public Health Baltimore, Maryland January 6, 2010.

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The American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services

Mental Health in Native Communities: Concepts and Care

Johns Hopkins University - Bloomberg School of Public Health

Baltimore, Maryland

January 6, 2010

Dale Walker, MD Patricia Silk Walker, PhD Douglas Bigelow, PhD

Bentson McFarland, MD, PhD, Laura Loudon, MS Michelle Singer

An Interdisciplinary Approach to Understanding the Health of Native Americans


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“Indian Country benefits significantly from health care reform legislation."

  • If health care reform becomes law, so does the Indian Health Care Improvement Act.

  • Opens up new revenue stream for the Indian Health system.

  • New money for long-term care, cancer screening and better mental health treatment

  • broader eligibility for Medicaid

  • Higher reimbursement rates in rural areas.

12-21-2009. www.marktrahant.com


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Empowering Tribal Nations reform legislation."

The President’s 2010 budget for the BIA - $2.3 billion – 7.1% increase.

  • “Self-determination, sovereignty, self-government, empowerment, and self-reliance are not abstract concepts; they are the tools that enable Indian Country to shape its own destiny.”

  • Violence, incidents of infant mortality, alcoholism, and substance abuse are far in excess of the rest of America

    Ken Salazar, Secretary of the Interior

    November 5, 2009


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IHS Budget and Goals reform legislation."

The President’s 2010 budget for the IHS - $4.03 billion - 13% increase - largest in 20 years.

  • To renew and strengthen partnership with tribes

  • In the context of national health reform, bring reform to IHS

  • To improve the quality and access to care for patients served by IHS

  • To have everything we do be transparent, accountable, fair, and inclusive

    Yvette Roubideaux , MD, IHS Director. Feb 4, 2010


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Native Communities reform legislation."

Advisory Council / Steering Committee

One Sky Center


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One Sky Center Partners reform legislation."

Tribal Colleges and Universities

Cook Inlet Tribal Council

Alaska Native Tribal Health Consortium

Prairielands ATTC

Red Road

Northwest Portland Area Indian Health Board

One Sky Center

Harvard Native Health Program

United American Indian Involvement

Jack Brown

Adolescent

Treatment Center

National Indian Youth Leadership Project

Tri-Ethnic Center for Prevention Research

Na'nizhoozhi Center


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One Sky Center Outreach reform legislation."


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Goals for Today reform legislation."

  • An Environmental Scan

  • Fragmentation and Integration

  • Behavioral Health Care Issues

  • Best Practice = Evidence-Based + Indigenous Knowledge - You do both

  • Treatment and prevention


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Native Health Problems reform legislation."

Alcoholism 6X

Tuberculosis 6X

Diabetes 3.5 X

Accidents 3X

Poverty 3x

Depression 3x

Suicide 2x

Violence?


American indians l.jpg
American reform legislation."Indians

  • Have same disorders as general population

  • Greater prevalence

  • Greater severity

  • Much less access to Tx

  • Cultural relevance more challenging

  • Social context disintegrated


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Agencies Involved in B.H. Delivery reform legislation."

1. Indian Health Service (IHS)

A. Mental Health

B. Primary Health

C. Alcoholism / Substance Abuse

2. Bureau of Indian Affairs (BIA)

A. Education

B. Vocational

C. Social Services

D. Police

3. Tribal Health

4. Urban Indian Health

  • State and Local Agencies

  • Federal Agencies: SAMHSA, VAMC, Justice


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Different goals reform legislation."

Resource silos

One size fits all

Activity-driven

How are we functioning?

(Carl Bell and Dale Walker 7/03)


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Best Practice reform legislation."

Culturally Specific

Outcome Driven

Integrating

Resources

We need Synergy and an Integrated System

(Carl Bell and Dale Walker 7/03)


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Behavioral Health Care Issues reform legislation."


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Adult Serious Mental Illness reform legislation."

By Race/Ethnicity: 2001

SAMHSA Office of Applied Studies, 2001


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Frequent Mental Distress reform legislation."

by Race/Ethnicity and Year

Percent

American Indian/

Alaskan Native**

African-American**

Hispanic

White**

Asian, Pacific Islander**

** Non-Hispanic

Year

* Zahran HS, et al. Self-Reported Frequent Mental Distress Among Adults — United States, 1993–2001. Centers for Disease Prevention and Control, MMWR 2004;53(41):963-966.


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Mental Illness: A Multi-factorial Event reform legislation."

Psychiatric Illness& Stigma

Edu., Econ., Rec.

Cultural Distress

Impulsiveness

Substance Use/Abuse

Hopelessness

Family Disruption/

Domestic Violence

Individual

Family History

Negative Boarding School

Psychodynamics/

Psychological Vulnerability

Historical Trauma

Suicidal

Behavior


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Adolescent Problems In Schools reform legislation."

Alcohol Drug Use

Fighting and Gangs

1. School Admin

2. Law

3. FBI

4. DEA

5. State MH

6. State A&D

7. Courts

8. Child Services

Bullying

Weapon Carrying

School

Environment

Sale of Alcohol

and Drugs

Sexual Abuse

Unruly Students

Truancy

Attacks

on Teachers

Staff

Domestic Violence

Drop Outs

12


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Key Adolescent Risk Factors reform legislation."

Aggressive/Impulsive

Substance Abuse

Depression

Trauma


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  • Tobacco use reform legislation."

  • Poor nutrition

  • Alcohol and other drug abuse

  • Behaviors resulting in intentional or unintentional injury

  • Physical inactivity

  • Risky sex

Six behaviors that contribute to serious health problems:


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0 reform legislation."

Suicide Among ages 15-17, 2001

Death rate per 100,000

2010

Target

Females

Males

Total

American

Indian

White

Black

Hispanic

Asian

Source: National Vital Statistics System - Mortality, NCHS, CDC.


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Suicide: A Native Crisis reform legislation."

Source: National Center for Health Statistics 2001


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North Dakota Teen Suicide Rates reform legislation."

(2000-2004 rate per 100,000 teens 13-19 years old)


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Disaster Defined reform legislation."

  • FEMA: A natural or man-made event that negatively affects life, property, livelihood or industry often resulting in permanent changes to human societies, ecosystems and environment.

  • NHTSA: Any occurrence that causes damage, ecological destruction, loss of human lives, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community area.

  • NOAA: A crisis event that surpasses the ability of an individual, community, or society to control or recover from its consequences.


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ADDICTION INVOLVES MULTIPLE FACTORS reform legislation."

Biology/Genes

Environment

DRUG

Brain Mechanisms

Addiction


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Lifetime, Annual and 30 Day Prevalence of Intoxication Among 224* Urban Indian Youth

R. Dale Walker, M.D. (4/99) *100% completion sample


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Changes in Lifetime Substance Use Among 224* Urban Indian Youth

Urban Indian Youth * Over Nine Years

Percentage ever used

R. Dale Walker, M.D. (4/99) * 100% Completion Sample


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Age of Onset of Drug Use Among Urban A IA 224* Urban Indian Youth(Walkers, 2008)


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Models of Care 224* Urban Indian Youth


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Domains Influencing Behavioral Health: A Native Ecological Model

Risk

Protection

Individual

Peers/Family

Community/Tribe

Society/Cultural


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Treatment Model

Brief Intervention

Universal/Selective Prevention

Spectrum of Intervention Responses

Thresholds for Action

No Problems

Mild Problems

Severe Problems

Moderate Problems


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The Intervention Spectrum for ModelBehavioral Disorders

Treatment

C

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t

i

f

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T

r

e

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t

f

o

r

K

n

o

w

n

Indicated—

Diagnosed

Youth

D

i

s

o

r

d

e

r

s

Prevention

Maintenance

C

o

m

p

l

i

a

n

c

e

Selective—

Health Risk

Groups

w

i

t

h

L

o

n

g

-

T

e

r

m

T

r

e

a

t

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e

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t

(

G

o

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:

R

e

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R

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)

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Universal—

General Population

(

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Source: Mrazek, P.J. and Haggerty, R.J. (eds.), Reducing Risks for Mental Disorders, Institute of Medicine, Washington, DC: National Academy Press, 1994.


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Risk and Protective Factors: Individual Model

  • Risk

  • Mental illness

  • Age/gender

  • Substance abuse

  • Loss

  • Previous suicide attempt

  • Personality traits

  • Incarceration

  • Failure/academic problems

  • Protective

  • Cultural/religious beliefs

  • Coping/problem solving skills

  • Ongoing health and mental health care

  • Resiliency, self esteem, direction, mission, determination, perseverance, optimism, empathy

  • Intellectual competence, reasons for living


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Individual Intervention Model

  • Identify risk and protective factors

    counseling

    skill building

    improve coping

    support groups

  • Increase community awareness

  • Access to hotlines other help resources


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Effective Family Intervention Strategies: Critical Role of Families

  • Parent training

  • Family skills training

  • Family in-home support

  • Family therapy

Different types of family interventions are used to modify

different risk and protective factors.


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Implications for Treatment Families

  • Teach adolescents how to cope with difficulties and adversity

  • Increase their repertoire of coping strategies

  • Cognitive therapy is most effective approach


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Sources of Strength Families

Access to Mental Health

Family Support

Positive Friends

Access to Medical

Spirituality

Caring Adults

Positive Activities

Generosity/Leadership


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Culture-Based Interventions Families

  • Story telling

  • Sweat Lodge

  • Talking circle

  • Vision quest

  • Wiping of tears

  • Drumming

  • Smudging

  • Traditional Healers

  • Herbal remedies

  • Traditional activities


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Effective Interventions for Adults Families

  • Cognitive/Behavioral Approaches

  • Motivational Interventions

  • Psychopharmacological Interventions

  • Modified Therapeutic Communities

  • Assertive Community Treatment

  • Vocational Services

  • Dual Recovery/Self-Help Programs

  • Consumer Involvement

  • Therapeutic Relationships


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Definition: Families

Indigenous Knowledge

  • Local knowledge unique to a given culture or society; it has its own theory, philosophy, scientific and logical validity, used as a basis for decision-making for all of life’s needs.


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Definitions: Families

Traditional Medicine

  • The sum total of health knowledge, skills and practices based upon theories, beliefs and experiences indigenous to different cultures…used in the maintenance of health.

    WHO 2002


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ID Best Practice Families

Best Practice

Clinical/services

Research

Mainstream

Practice

Traditional

Medicine



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An Ideal Intervention Families

  • Broadly based:

    Includes individual, family,

    community, tribe, and society

  • Comprehensive:

    Prevention: Universal, Selective,

    Indicated

    Treatment

    Maintenance


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Adventure Therapy Families

“Natural Highs Program”

Transformation process

Experiential activities

Relationship building

Changing the way you live and think

Changing how you think and how you believe about life and yourself

Creation of challenge in a safe environment

Horses, Canoes, Tradition Camps

Choctaw Nation of Oklahoma


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Meth Free Crow Walk: Youth as our Warriors in Reclaiming our Nation

Meth Free Crowalition

  • Establish a “War Against Meth” Focus on accountability, prevention, intervention, and treatment

  • Combine forces for Unity.

  • Diverse community representation

  • Youth and Community Development: mentorship, leadership, trust, establish community norms


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Integrated Treatment Nation

Premise: treatment at a single site, featuring coordination of treatment philosophy, services and timing of intervention will be more effective than a mix of discrete and loosely coordinated services

Findings:

  • decrease in hospitalization

  • lessening of psychiatric and substance abuse severity

  • better engagement and retention

    (Rosenthal et al, 1992, 1995, 1997; Hellerstein et al 1995.)


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Comprehensive school planning Nation

  • Prevention and behavioral health programs/services on site

  • Handling behavioral health crises

  • Responding appropriately and effectively after an event occurs


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Community Driven/School Based Prevention Interventions Nation

  • Public awareness and media campaigns

  • Youth Development Services

  • Social Interaction Skills Training Approaches

  • Mentoring Programs

  • Tutoring Programs

  • Rites of Passage Programs


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Partnered Collaboration Nation

State/Federal

Community-Based

Organizations

Grassroots Groups

Research-Education-Treatment


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Unified Services Plan Nation

  • Case management should address:

  • Mental health

  • Education/vocation

  • Leisure/social

  • Parenting/family

  • Housing

  • Financial

  • Daily living skills

  • Physical health


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Five Key Principles Nation Evidence-based predictors of change

  • Understand & Involve the Community

  • Focus on major problems

  • Select the right change agent

  • Seek ideas from outside the field and organization

  • Evaluate


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Common Characteristics of Successful Native Programs Nation

  • Leadership

  • Mobilization Community driven

  • Public health approach

  • Strength based

  • Culturally informed

  • Proactive


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Bethesda, Maryland Nation

October 14, 2009

NIDA American Indian Research Scholars Mentorship Program


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Location of Mentors = Nation and Mentees = in Project

X

X

X

X

X

X

X

X

X


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– Albert Einstein Nation

“We cannot solve

problems by using

the same kind

of thinking we used

when we created

them.”


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Contact us at Nation

503-494-3703

E-mail

Dale Walker, MD

[email protected]

Or visit our website:

www.oneskycenter.org


Bottom line l.jpg

  • Deal with Epistemological Gulf Nation

  • Know limitations of Evidence in EBI

  • Agree upon “Practice Improvement” Goal

  • Make credibility gains with “Scientific Framework” for Description

  • Use existing practices and knowledge as evidence for similar CBI

Bottom Line




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Problem is bigger, broader and more complex than current solutions

  • Broad-based, integrated, interagency changes are needed

  • State, county, and city relationships to be developed with tribes and communities

  • Training and tribal leadership development

  • A Marshall Plan for all Native America that effects: economics, housing, social services, education, law/governance, and health


Why do people take drugs l.jpg

To feel good solutions

To have novel:

Feelings

Sensations

Experiences

AND

To share them

To feel better

To lessen:

Anxiety

Worries

Fears

Depression

Hopelessness

Withdrawal

Why do People Take Drugs?


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